Practice guidelines, appropriateness criteria and other parameters based on outcome and effectiveness research are gaining increased acceptance as a way to improve clinical outcomes and quality of care. Disseminating and implementing guidelines and criteria in clinical settings to achieve lasting improvements in clinical practice patterns remain a challenge. The Academic Medical Center Consortium (AMCC) proposes to involve practicing physicians in a structured review of appropriateness criteria for four major surgical procedures with widespread use. Through this process, the AMCC plans to identify obstacles and supporting factors that could affect the dissemination and use of appropriateness criteria and possibly other clinical practice guidelines. The hypothesis is that voluntary involvement of practitioners in the criteria review process will enhance the likelihood that their subsequent use and acceptance will be lasting. The Consortium is involved in developing appropriateness criteria for coronary artery bypass graft surgery, abdominal aortic aneurysm resection, cataract extraction and carotid endarterectomy. This proposed one-year project is designed to test a model review and dissemination process by (1) engaging affected clinicians in a structured review of the criteria, (2) soliciting their reactions to the criteria and identifying any clinical modifications that would improve them, (3) soliciting predictions of results from applying the criteria with and without any modifications, and (4) comparing actual results to predictions. The project will also compare the structured review process against dissemination processes for previous guidelines and major studies for three of the procedures.